Introduction

In India, about 99.5 million (10.7%) of all adults smoke tobacco, whereas 199.4 million (21.4%) use smokeless tobacco.1 To tackle the tobacco menace, the WHO introduced six practical, affordable and achievable measures called MPOWER measures for helping countries to implement specific provisions of the WHO Framework Convention on Tobacco Control (FCTC).2 WHO FCTC regards ‘packaging and labelling of tobacco products’ as one of the measures to reduce the demand for tobacco and included this under its core demand reduction provisions contained in article 11.3

In India, the Cigarettes and Other Tobacco Products Act (COTPA) was enacted in 2003.4 The COTPA packaging and labelling rules were mandated in 2009, amended in 2014 and came into effect in April 2015.5 6 Studies investigating the compliance of manufacturers with regard to the COTPA prescribed packaging and labelling rules of tobacco products sold in India are scarce. Given that the prevalence of tobacco use among people living in slum areas of India is much higher than among the general population,7–9 and documented indications of violations of COTPA in these areas where there are widespread accessibility and availability of a large variety of tobacco products,10 this study sought to understand the extent of compliance with the packaging and labelling rules in slum areas of Bhubaneswar city, India.

Materials and methods

The cross-sectional study was conducted in the slum areas of Bhubaneswar, the capital city of Odisha during the period between November 2016 and March 2017. Bhubaneswar is divided into three geographical zones (North, South East and South West) having 67 wards and 436 slums. Multistage sampling technique was used to select the study areas. Out of the three zones, the North zone was randomly selected, as were 50% of the wards in this zone, and one slum from each ward to constitute the final 11 study clusters.

All the retail shops in the selected slums were identified by walking through streets one-by-one and visiting each shop, and the retailers were asked about the sale of tobacco. The retail shops found closed after at least two visits on different days were excluded from the study. In total, 134 retail outlets were visited and 81 (60.4%) of these sold tobacco. One packet from each brand of tobacco product available in the shops was purchased to achieve the maximum representation of available tobacco brands, with no duplicates. Overall, the study sample consisted of 42 different brands of tobacco products, 23 in smoking form (cigarette, bidi) and 19 in smokeless form (gutkha, khaini, betel quid with tobacco).

All collected tobacco packages were analysed with the help of a checklist developed from the COTPA packaging and labelling rules,5 6 that specify:

1. The Specified Health Warning (SHW) are required to cover at least 85% of the principal display area of the package of which 60% should be covered by Pictorial Health Warning (PHW) and 25% by Textual Health Warning (THW). PHWs include images of throat cancer and oral cancer for smoking and smokeless form of tobacco respectively. THWs include the word ‘WARNING’ on both forms of tobacco packaging with the phrases ‘Smoking causes throat cancer’ and ‘Tobacco causes mouth cancer’ for smoking and smokeless tobacco respectively. The word ‘WARNING’ should appear in white font on a red background and both phrases in white font on a black background. The SHW should be positioned on the top edge of the package and in the same direction as the information on the principal display area. The SHW should appear on both sides of the package, on the largest panels, and for cylindrical and conical types of packages, it should appear diametrically opposite to each other on two largest sides or faces of the package.

2. No message or image should be inscribed on the package that directly or indirectly promotes the use of a specific tobacco brand or tobacco usage in general or any matter or statement which is inconsistent with or detracts from the specified health warning.

3. There should not be any misleading or deceptive information on a package that is likely to create a false impression about the characteristics, health effects, health or other hazards of the tobacco products. This prohibition includes the use of words or descriptors such as light, ultra light, mild, ultra mild, low tar, slim, safer or similar words or descriptors.

4. Every package should contain the name, origin and quantity of the product, name and address of the manufacturer or packer, and date of manufacture.

5. The image of SHW should appear for a period of 12 months from the date of commencement of the rules after which it must be replaced with another image of SHW which would appear for the next 12 months and the distributors/retailers of tobacco products should not distribute or sell any package having the SHW of the expired period of 12 months.

Visual analysis of the product specification details and SHWs was conducted and surface area occupied by these warnings was calculated with the help of a calibrated ruler. Data were analysed using SPSS V.21.0 software for descriptive statistics.

Results

Of the 42 tobacco brands, 18 (42.8%) had misleading descriptors such as balanced taste, refined taste, smooth flow, honeydew, mint, fruity cool and so on printed on their packages. Similarly, written promotional messages like impeccable tobacco, finest tobacco with cloves, commitment to quality, special filter, premium filter, right standard and so on were present on 18 (42.8%) brands, whereas 11 (26.2%) brands had picture promotional messages such as images of gods and goddesses, flowers, leaves, nature, globe and so on. On 27 (64.3%) tobacco brands, PHWs occupied less than the prescribed size of 60% of the principal display area of the package, whereas on 29 (69.0%) tobacco brands, THWs occupied less than the prescribed size of 25% of the principal display area. The total area of the SHW met the prescribed size of 85% of the principal display area on only 13 (30.9%) brands (table 1).

Discussion

SHWs on most of the tobacco brands, particularly smokeless tobacco products, were non-compliant with COTPA specifications. Proper positioning and larger size of health warnings on packages are likely to be more visible, more effective and reduce space for the brand’s promotional messages.3 11 Health warnings on tobacco product packages are a highly cost-effective means of communication as they can increase people’s awareness regarding harms of tobacco use, promote cessation and reduce tobacco consumption.1 11–13 The study also revealed the presence of misleading descriptors and promotional messages on a variety of brands of tobacco marketed in slums. This may create a false impression among product users that particular tobacco products are less harmful than others, thereby reducing their chance of quitting. For effective implementation of tobacco control measures, governments must protect public health policies from the commercial and other vested interests of the tobacco industries and enforce bans on tobacco promotion and sponsorship.2

The study has limitations. The findings of the study may not be generalisable to a wider geographic area as it was carried out in one zone of one state in India and compliance with COTPA, or enforcement measures, might vary by state. Also, only 42 brands of tobacco products were analysed for packaging and labelling compliance which may not be a true representation of all brands of tobacco products. Further research is needed to understand if the lack of compliance with the COTPA regulations is more widespread across India and if the same pattern of differences in compliance between combustible and smokeless tobacco is found elsewhere. Strict compliance with COTPA guidelines by the manufacturers, distributors and retailers of tobacco products is essential, but appropriate enforcement of the regulations is critical to achieving that goal.